Provider Demographics
NPI:1023655792
Name:DAVIS, GREGORY WAYNE (HIS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:WAYNE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 JOHNSTON ST STE 502
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-5334
Mailing Address - Country:US
Mailing Address - Phone:337-704-2228
Mailing Address - Fax:337-704-2240
Practice Address - Street 1:2121 AIRLINE DR # 600
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3174
Practice Address - Country:US
Practice Address - Phone:318-742-3525
Practice Address - Fax:318-742-3539
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSHA0676237700000X
LA1315237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist